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Your Hair Characteristics
Age:
Gender:
Hair Color:
Skin to hair color:
Hair Description:
Hair Texture:
Current Stage of Baldness:	Click here for a description of each


Your Hair Loss History
At what age did you begin to notice hair loss?
Are you still losing hair?
If “no”, for how long has your hair loss pattern stabilized?
Describe your family history of hair loss (select all that has suffered from thinning and balding):
Mother Father Brothers Grandfathers Uncles
What treatment options have you already explored (select all that apply):
Hair Transplantation Hair System (Toupee) Rogaine Propecia Laser Hair Therapy Other
Have you ever had a hair transplantation consultation?
Have you ever undergone a hair transplantation?
If “yes”, please describe:
Please describe your current medical condition and current medications:

Your Contact Information
First Name: *
Last Name:
Email Address: *
Street Address - Line 1:
Street Address - Line 2:
City:
State / Province: *
Zip / Postal Code:
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Phone:
I prefer to be contacted by:
Preferred Nu/Hart Clinic:
How did you hear about us?

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Please click on the submit button only once. It make take a few moments for your information to process.
Upon submission of your information, you will be taken to a new page where you will then have the option of uploading your hair loss photos for review by a Nu/Hart physician.